Migraine-like visual aura: Can it be an early-onset symptom of astrocytoma?

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Department of Neurology, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey

Submitted (Başvuru tarihi) 03.12.2016 Accepted after revision (Düzeltme sonrası kabul tarihi) 03.06.2017 Available online date (Online yayımlanma tarihi) 25.10.2018 Correspondence: Dr. Uygar Utku. Kocaeli Derince Eğitim ve Araştırma Hastanesi, 41900 Kocaeli, Turkey.

Özet

Görme alanında fotopsi, fortifikasyon spektrumu ve parlama skotomu, görsel auralı migrenin karakteristik tanısal özellikleridir. Olguların büyük bir çoğunluğunda tanı ileri tetkiklere gerek kalmaksızın yapılabilmektedir. Bu makalede, astrositomlu üç ardı-şık olgu sunuldu ve migren benzeri görsel auranın klinik özellikleri tartışıldı.

Anahtar sözcükler: Astrositoma; migren benzeri görsel aura. Summary

Photopsia, fortification spectra, and the slow propagation of a scintillating scotoma across the visual field are typical diagnos-tic features of the visual aura of migraine. In the vast majority of cases, the diagnosis can be made without the need for further investigations. Herein, we report three consecutive cases with an astrocytoma and discuss clinical features of migraine-like visual aura.

Keywords: Astrocytoma; migraine like visual aura.

Introduction

Photopsia, fortification spectra, and the slow propa-gation of a scintillating scotoma across the visual field are typical diagnostic features of the visual aura of migraine. In the vast majority of cases, the diagno-sis can be made without the need for further inves-tigations.[1]_{Typical migraine-like visual aura due to a}

structural lesion with the absence of other neurolog-ical signs or symptoms is rare.[2,3]_{Herein, we report}

three consecutive cases with an astrocytoma and discuss clinical features of migraine-like visual aura in the light of the literature data.

Case Reports

Case–1: A 32-year-old male was admitted with a

two-year history of migraine headache-associated with visual aura. He suffered from gradually increas-ing in frequency of headache and changincreas-ing in the characteristics of visual aura for two months. The pa-tient described the visual aura as repetitive flashes of

light every five seconds and lasting approximately two minutes in the right visual field. He experienced five to 15 episodes in this period and several min-utes later by a moderate to severe right-sided throb-bing headache. There were no identifiable triggers for these attacks. There was also associated nausea, vomiting, phonophobia or photophobia. He had no other neurological or ophthalmological symptoms. His physical, neurological, and fundoscopic exami-nation findings, including blood pressure and men-ingeal signs, were normal. Complete blood count and routine biochemistry results, including liver and renal function tests and erythrocyte sedimentation rate, were normal. Electroencephalography (EEG) re-vealed normal findings. Cranial magnetic resonance imaging (MRI) revealed a lesion without any contrast enhancement within the right frontal lobe, consis-tent with a low-grade astrocytoma (Fig. 1). Stereo-tactic biopsy was, then, performed. The biopsy result was consistent with a low-grade astrocytoma.

Migraine-like visual aura: Can it be an early-onset symptom of

astrocytoma?

Migren benzeri görsel aura: Astrositomalı hastalarda erken bir başlangıç bulgusu

olabilir mi?

Gökhan EVCILI, Muhammed Nur ÖĞÜN, Uygar UTKU

Agri 2018;30(4):202-205 doi: 10.5505/agri.2017.77598 C A S E R E P O R T PAINA RI OCTOBER 2018 202

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OCTOBER 2018 203 Case–2: A 33-year-old female was admitted with a

new-onset of episodic migraine-like visual aura for six months. The aura consisted of fortification spec-tra (expanding zigzag pattern) and spec-transient flashing white lights always recurring in the left visual field followed by a moderate to severe left-sided throb-bing headache several minutes later, although it did not always occur (acephalgic migraine with visual aura). Episodes of aura lasted minutes and were as-sociated with nausea, vomiting, photophobia, and headache lasting several hours; relieved by sleep and oral analgesia. She had a positive family history, but no personal history of migraine. Her physical, neurological, and fundoscopic examination find-ings, including blood pressure and meningeal signs, were normal. Complete blood count and routine

biochemistry results, including liver and renal func-tion tests and erythrocyte sedimentafunc-tion rate, were normal. Electroencephalography revealed normal findings. Cranial MRI revealed a large lesion with a mild contrast enhancement within the right occipi-tal lobe, consistent with an astrocytoma (Fig. 2).

Case–3: A 23-year-old female was admitted with an

increased frequency of headaches with visual aura for six months. The aura began as a star-shaped tran-sient flashing white lights always recurring in the right visual field and, then, triangular zigzag lines fol-lowed by a moderate to severe left-sided throbbing headache several minutes later. Episodes of aura lasted minutes and were associated with nausea, photophobia, and headache lasting several hours;

Figure 1. T2-weighted, axial, and fluid-attenuated inversion recovery coronal magnetic resonance imaging

scans showing a well-defined focal mass lesion in the right frontal lobe.

Figure 2. T2-weighted, axial, and fluid-attenuated inversion recovery coronal magnetic resonance imaging

scans showing a well-defined focal mass lesion in the right occipital lobe.

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relieved by sleep and oral analgesia. There was no family or personal history of migraine. Her physical, neurological and fundoscopic examination find-ings, including blood pressure and meningeal signs, were normal. Complete blood count and routine biochemistry results, including liver and renal func-tion tests and erythrocyte sedimentafunc-tion rate, were normal. Electroencephalography revealed normal findings. Cranial MRI revealed a lesion without any contrast enhancement within the left occipital lobe, consistent with a low-grade astrocytoma (Fig. 3).

Discussion

A careful history and physical examination still remain the mainstays of headache assessment. Although a very low number of patients with headaches have brain tumors, recognition of tumor-associated head-aches is of utmost importance. In a study including 85 patients with a brain tumor, Schankin et al.[4]

ex-amined the characteristics of brain tumor-associated headache. The authors found that headache was the sole symptom in only 2%. In another study, Forsyth et al.[5]_{reported that headaches were similar to}

ten-sion-type in 77%, migraine-type in 9%, and other types in 14% of 111 patients with a brain tumor. Our cases presented with only migraine-type headache with migraine-like visual aura due to an astrocytoma. Furthermore, to critically examine the true nature of visual aura secondary to structural lesions and compare them to those of migraine, we examined three cases presenting with migraine-like visual aura

caused by focal cerebral lesions. Neuronal hypercitability or cortical spreading depression can ex-plain the comorbidity of disorders, such as migraine, epilepsy and acquired brain lesions, the overlap in clinical features, particularly visual aura.[2,6]_This

mechanism may explain the discorelation between the localization of structural lesion and visual aura. Diagnostic criteria for typical migraine visual aura are shown in Table 1.[7]_{Our cases experienced visual}

aura fulfilling the diagnostic criteria for migraine. Considering the common features of these three cases (Table 2); one of them was increased frequency or new-onset of visual aura. All cases had typical vi-sual aura with varying disease duration. Brief vivi-sual aura for seconds or less than five minutes was seen. The diagnostic criteria for migraine with aura stipu-late that the aura symptoms develop gradually over 5 or more minutes and last no more than 60 minutes.

[7]_{Our experience however suggests that visual aura}

caused by cerebral lesions cannot be reliably differ-entiated from migraine on the basis of the duration of the aura. The other was changing in the character-istics of visual aura; such as repetitive flashes or tran-sient flashing white lights with fortification spectra. The last one was the visual aura without headache. Based on the literature review on migraine-like visual aura due to focal cerebral lesions, the red-flag warn-ing features of the visual aura include stereotypi-cal visual aura, increasing frequency of visual aura, altered patterns or characteristics of chronic visual aura, any unexplained visual field defects, and

nega-Figure 3. T2-weighted, axial, and fluid-attenuated inversion recovery coronal magnetic resonance imaging

scans of a focal mass lesion in the right occipital lobe.

PAINA RI

OCTOBER 2018 204

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tive visual phenomena or subjective persistence of a scotoma following a typical visual aura.[2]

In conclusion, these cases highlight the importance of being aware that migraine-like visual aura may lead to the diagnosis of a brain structural lesion. The study has complied with the principles of the Dec-laration of Helsinki.

Conflict-of-interest issues regarding the author-ship or article: None declared.

Peer-rewiew: Externally peer-reviewed.

References

1. Russell MB, Olesen J. A nosographic analysis of the migraine aura in a general population. Brain 1996;119(Pt 2):355–61. 2. Shams PN, Plant GT. Migraine-like visual aura due to focal

cerebral lesions: case series and review. Surv Ophthalmol 2011;56(6):135–61. [CrossRef]

3. Magrotti E, Frascaroli G, Mariani G. Left temporal glioma presenting as migraine with typical aura. Ital J Neurol Sci 1992;13(5):444. [CrossRef]

4. Schankin CJ, Ferrari U, Reinisch VM, Birnbaum T, Goldbrun-ner R, Straube A. Characteristics of brain tumour-associat-ed headache. Cephalalgia 2007;27(8):904–11. [CrossRef]

5. Forsyth PA, Posner JB. Headaches in patients with brain tu-mors: a study of 111 patients. Neurology 1993;43(9):1678–83. 6. Vincent MB. Vision and migraine. Headache 2015;55(4):595–9. 7. Headache Classification Subcommittee of the Interna-tional Headache Society. The internaInterna-tional classification of headache disorders: 2nd. Cephalalgia 2004;24:1–160.

Table 1. Diagnostic criteria for typical migraine visual aura

I. At least two attacks fulfilling criteria II-IV

II. Aura consisting of at least one of the following, but no motor weakness

A. Fully reversible visual symptoms including positive features (e.g., flickering lights, spots, or lines) and/or negative features (i.e., loss of vision)

B. Fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative features (i.e., numbness)

C. Fully reversible dysphasic speech disturbance III. At least two of the following

A. Homonymous visual symptoms and/or unilateral sensory symptoms

B. At least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes

C. Each symptom lasts ≥5 and ≤60 minutes

IV. Headache begins during the aura or follows aura within 60 minutes V. Not attributed to another disorder

*International Classification of Headache Disorders (ICHD).

Table 2. Characteristics of three patients with an astrocytoma and the astrocytoma case reported initially

Case 1 Case 2 Case 3 Case from the literature3

Age (years) 32 33 23 31

New onset or old aura Old New Old New Duration of aura (minutes) 2 15 15 15 Change in frequency of aura Increase Increase Increase Increase Location of visual aura in visual field Right Left Right Bilateral Location of headache Right Left Left Left sided Location of lesion Right frontal Right occipital Left occipital Left temporal Headache associated with aura Yes Yes Yes Yes